Monkeypox and Pregnancy: What

Maternal-Fetal Medicine Subspecialists

Need to Know
8.16.22 (update of draft originally posted on 7.19.22)
The Society for Maternal-Fetal Medicine (SMFM); Naima T. Joseph, MD; Brenna Hughes, MD;
Jeffrey Kuller, MD; and Judette Louis, MD, MPH

Introduction
Since May 2022, the Centers for Disease Control and Prevention has been tracking cases of
Monkeypox virus infection in 47 states, Washington, D.C., and Puerto Rico. More than 28,000
cases in 88 countries have been confirmed globally, with 27,875 cases occurring in countries that
have not historically reported monkeypox. Although data are limited, pregnant or breastfeeding
people may be at heightened risk for worsened disease severity and adverse perinatal outcomes
associated with monkeypox infection. This document complements the rapidly evolving
guidance from the Centers for Disease Control and Prevention, focusing on unique maternal,
fetal, and perinatal clinical considerations.

What is monkeypox, and how is it transmitted?

The monkeypox virus is an orthopoxvirus that exhibits features similar to smallpox or variola
virus. Monkeypox virus has two different strains, one of which, the Congo basin, is associated
with more severe illness and case fatality. The World Health Organization reports that the
dominant circulating strain is the West African clade, which has a case fatality ratio of 3% to
6%.

Human-to-human transmission occurs from (1) direct contact with an infected rash, scab, or
body fluid; (2) respiratory secretions during prolonged or intimate physical contact; and (3)
contact with contaminated items, such as clothing or bedding. A person with monkeypox
infection is considered contagious from initial viral prodrome and develop of rash until the
lesions have fully healed and new skin has formed over the scabs. It is not clear whether
asymptomatic spread occurs, nor is it clear if transmission can also occur through vaginal or
seminal fluids. Perinatal infection can occur through transplacental transmission or during close
contact during and after birth.

Zoonotic (animal-to-human) transmission also occurs following direct contact with the blood,
bodily fluids, or cutaneous or mucosal lesions of infected animals.

What is the clinical presentation of monkeypox virus?

Patients may present with fever, lymphadenopathy, malaise, headache, myalgia, and rash. A
vesicular or pustular rash typically develops 1 to 4 days after initial symptoms and can persist for
2 to 4 weeks. A wide spectrum of lesions have been reported but most often they are firm,
vesicular, well-circumscribed or confluent. Historically, the lesions begin centrally and progress
outwards to hands, feet or face. However in the current outbreak, the lesions have begun on or
near the oral, genital and anal region.

Data regarding risk factors for infection and disease progression in this outbreak are informed
from a recent case series of 528 laboratory-confirmed infections diagnosed between April 27 and
June 24, 2022, at 43 sites in 16 countries. Among the group, 13% required hospital admission for
pain and symptom control, including severe pain, severe pharyngitis limiting oral intake, acute
kidney injury, and myocarditis, and 5% of the total cohort received monkeypox-specific
treatment. No deaths occurred.

What are the pregnancy implications of monkeypox virus infection?

It is unknown if pregnant people are more susceptible to monkeypox virus acquisition or if the
disease is more severe during pregnancy. However, an increased risk of maternal mortality and
morbidity has been documented with other poxvirus infections.

Monkeypox virus can be transmitted to the fetus during pregnancy or to the newborn by close
contact during and after birth. A commentary examined 5 cases with documented perinatal
outcomes reported in the literature. Among these 5 cases, 2 resulted in spontaneous abortion, 1
resulted in stillbirth, and 1 resulted in the preterm birth of a neonate with congenital monkeypox
infection and subsequent neonatal death. Other individual contributing circumstances are not
known. The frequency and risk factors for disease severity and adverse pregnancy outcomes are
also unknown.

What is the evaluation for a person with suspected monkeypox

infection?
For any patient with a rash or anogenital lesion, clinicians should collect a detailed travel and
sexual history and perform a physical examination that includes an evaluation of lymph nodes
and oral, genital, and rectal mucosa.
Clinicians should isolate their patient in a single-person room if available. Clinicians should
consult their infection and control practice in their hospital system, their state health department
(State Contacts), or CDC through the CDC Emergency Operations Center (770-488-7100) as
soon as monkeypox is suspected to ensure proper testing and reporting. Two-step diagnostic
testing includes obtaining multiple samples from different lesions and sending the sample for an
initial orthopoxvirus polymerase chain reaction test. If orthopoxvirus is confirmed, the
specimens are sent for monkeypox virus-specific testing. Co-infections with monkeypox virus
and sexually transmitted infections (STIs) have been reported; therefore, a broad testing
approach for STIs should be considered.

Additionally, clinicians should use appropriate infection prevention measures when collecting
specimens for monkeypox evaluation. These measures include the use of personal protective
equipment such as eye protection, gown, gloves, and a particulate respirator approved by the
National Institute for Occupational Safety and Health (NIOSH), e.g. N95.

What treatment can be offered during pregnancy and lactation?

Pregnant, recently pregnant, and breastfeeding people should be prioritized for medical treatment
if needed. Most infected people will have a mild, self-limiting illness. However, CDC guidance
indicates that patients who should be considered for treatment following infection include:
1. People with severe disease and one or more complications requiring hospitalization (ie,
hemorrhagic disease, encephalitis, secondary bacterial skin infection, poor oral intake,
severe pain)
2. People at high risk of severe disease, including pregnant or breastfeeding people, people
with immunocompromise, people with a history of active exfoliative skin conditions and
pediatric patients, particularly those younger than age 8.

There are no specific treatments for monkeypox virus infection. Two antivirals and vaccinia
immune globulin are available from the Strategic National Stockpile under expanded access
investigational new drug protocols held by the Centers for Disease Control and Prevention. The
risks and benefits of treatment should be discussed with the patient using shared decision-
making.

Most people with infection have a mild, self-limiting illness. Severe disease includes
hemorrhagic disease, sepsis, encephalitis, or other conditions requiring hospitalization.
Persons with monkeypox infection should also be counseled to isolate for the duration of the
illness. The decision to treat and monitor a pregnant person as an outpatient or inpatient should
be individualized. As CDC recommends, if treatment is indicated, tecovirimat should be
considered the first-line antiviral drug for pregnant, recently pregnant, and breastfeeding people
(see Table).
Table. Drugs Used for Treatment of Monkeypox

Pregnancy Breastfeeding
Drug Availability Administration
data data
Tecovirimat Limited to Weight-based Pregnant Breastfeeding
(TPOXX, health patients not patients not
ST-246) department/CDC Intravenous and included in included in
expanded access oral pharmacokinetic pharmacokinetic
protocol studies studies

Adverse events Not known if

not observed in present in
animal breastmilk
reproduction
studies
Cidofovir Off-label Intravenous No human data No human data
(Vistide)
Available for Contraindicated Animal data Breastfeeding
use in an in patients with suggest not
outbreak setting CrCl embryolethality recommended
≤55mL/min, and during period of
serum Cr > 1.5 teratogenicity exposed lesions
mg/dL; use with
or within 7 days
of nephrotoxic
agents
Availability Oral Animal data No human data
Brincidofovir limited to suggest
(CMX001, Strategic Weight-based embryolethality Breastfeeding
Tembexa) National and not
Stockpile Dose adjustment teratogenicity recommended
distribution for hepatic during period of
exposed lesions
impairment

No
contraindications
in manufacturer
labeling
Vaccinia Limited to Intravenous No human or No human or
intravenous health animal data animal data
immune department/CDC
globulin expanded access Immune Immune
(VIGIV) protocol globulins globulins
known to cross known to cross
the placenta the placenta
without severe without severe
adverse effects adverse effects
CDC, Centers for Disease Control and Prevention; Cr, creatinine; CrCl, creatine clearance
Vaccines against monkeypox and administration during pregnancy
Two vaccines directed against monkeypox are currently available. ACAM2000 is a replicating
viral vaccine licensed for the prevention of smallpox. It is contraindicated in pregnant or
breastfeeding people due to the risk of pregnancy loss, congenital defects, and vaccinia virus
infection.
JYNNEOS is a live, nonreplicating viral vaccine licensed for the prevention of both smallpox
and monkeypox disease. Available human data on JYNNEOS administered to pregnant people
are insufficient to determine if there are any vaccine-associated pregnancy-specific benefits or
risks. Animal studies have not shown evidence of harm, and the vaccine should not be withheld
from pregnant individuals who otherwise would be eligible in the context of shared decision-
making. The JYNNEOS vaccine requires two doses administered 28 days apart for maximum
effectiveness. Currently, JYNNEOS is in limited supply and available to individuals through
state health departments who meet the following criteria:
• Postexposure prophylaxis either within 4 days of a known exposure to monkeypox to reduce
the likelihood of infection or between 4 and 14 days postexposure which may reduce the
severity of symptoms
• Known contacts of monkeypox cases identified by public health via case investigation,
contact tracing, and risk exposure assessments (may include sexual partners, household
contacts, and healthcare workers)
• Presumed contacts who meet the following criteria:
 Know that a sexual partner in the past 14 days was diagnosed with monkeypox; or
 Had multiple sexual partners in the past 14 days in a jurisdiction with known monkeypox
Coadministration with other vaccines: JYNNEOS typically may be given at the same time as
other vaccines. However, because of the observed risk for myocarditis after receipt of
ACAM2000 vaccine and mRNA and Novavax COVID-19 vaccines and the unknown risk for
myocarditis after JYNNEOS, some people might consider waiting 4 weeks after JYNNEOS or
ACAM2000 before receiving a Moderna, Novavax, or Pfizer-BioNTech COVID-19 vaccine. If
an orthopoxvirus vaccine is recommended for prophylaxis in the setting of an outbreak,
orthopoxvirus vaccination should not be delayed because of recent receipt of a Moderna,
Novavax, or Pfizer-BioNTech COVID-19 vaccine; no minimum interval between COVID-19
vaccination with these vaccines and orthopoxvirus vaccination is necessary (CDC Monkeypox
Vaccination).

Antenatal fetal surveillance for patients with suspected or confirmed

monkeypox virus
Currently, the data are insufficient to guide recommendations for antepartum fetal surveillance. It
is unknown when or how often vertical transmission occurs during pregnancy, nor how infection
during pregnancy contributes to stillbirth risk. Fetal surveillance during acute illness should be
guided by maternal disease severity, gestational age, and comorbid conditions. Clinicians can
consider a follow-up growth ultrasound once the illness has resolved and following completion
of the isolation period.
When and how should delivery occur in patients with monkeypox?
The relationship between the timing of infection in pregnancy, risk for congenital infection, and
transplacental vs. intrapartum transmission is unknown. It is unclear whether preterm or early
term delivery protects against adverse neonatal outcomes, nor is it clear whether cesarean
delivery mediates the risk of perinatal infection. There has been no clear evidence of
transmission through vaginal fluids; however, these data are limited. Further, nothing is known
regarding genital tract shedding.

Currently, in the absence of obstetric indications, SMFM does not recommend preterm or early
term delivery. Decisions regarding the mode of delivery should be individualized. Cesarean
delivery can be considered if lesions are present and cannot be covered in or near the vaginal,
anal, or perineal regions to reduce the risk of neonatal contact during delivery. However, the
guidance will continue to evolve as pregnancy-specific data emerge.

Can patients with monkeypox virus breastfeed?

Mother-Infant Contact
While the benefits of skin-to-skin contact and rooming-in on breastfeeding are well-known,
given the risk of neonatal transmission of monkeypox virus with close contact and the potential
for severe disease in newborns, direct contact between a patient in isolation for monkeypox and
their newborn is not advised. See CDC for additional considerations for mother-infant contact.

Infant Feeding with Breast Milk

Breast milk is the best source of nutrition for most newborns, and it provides protection against
many illnesses. However, given that the monkeypox virus is spread by close contact and neonatal
monkeypox infection may be severe, breastfeeding should be delayed until criteria for
discontinuing isolation have been met (i.e., all lesions have resolved, the scabs have fallen off,
and a fresh layer of intact skin has formed). Breast pumping will allow patients to maintain
supply during a breastfeeding pause. However, until there are data evaluating the risk of
transmission through breastmilk, current recommendations are to discard breastmilk pumped
until the person is considered no longer infectious.

See CDC and AAP for additional information on infant feeding with breastmilk.

Infection Control
Infection control practices for the care of patients who are pregnant with monkeypox infection
are the same as those for patients who are not pregnant with monkeypox infection – including
appropriate isolation of patients with monkeypox; training for healthcare personnel on maternity
and newborn care units on correct adherence to infection control practices and PPE (gown,
gloves, eye protection, and NIOSH-approved particulate respirator equipped with an N95 filter
or higher) use and handling; and ensuring sufficient and appropriate PPE supplies are positioned
at all points of care.

Further, visitors to pregnant or postpartum patients with monkeypox should be limited to those
essential to the patient’s care and wellbeing. The use of alternative mechanisms for patient and
visitor interactions, such as video-call applications, should be encouraged for any additional
support.

Visitors should have no direct contact with the patient.

Further resources:

CDC: https://www.cdc.gov/poxvirus/monkeypox/index.html

ACOG: https://www.acog.org/clinical-information/physician-faqs/obstetric-care-considerations-
monkeypox

Suggested Citation: Society for Maternal-Fetal Medicine (SMFM). Monkeypox and Pregnancy: What
Maternal-Fetal Medicine Subspecialists Need to Know. Washington, DC: SMFM; 2022. Available at:
https://www.smfm.org/monkeypox. Retrieved [enter date].